Treatment for Alexia With Agraphia Following Left Ventral Occipito-Temporal Damage: Strengthening Orthographic Representations Common to Reading and Spelling

Abstract

Purpose: Damage to left ventral occipito-temporal cortex can give rise to written language impairment characterized by pure alexia/letter-by-letter (LBL) reading, as well as surface alexia and agraphia. The purpose of this study was to examine the therapeutic effects of a combined treatment approach to address concurrent LBL reading with surface alexia/agraphia.

Method: Simultaneous treatment to address slow reading and errorful spelling was administered to 3 individuals with reading and spelling impairments after left ventral occipito-temporal damage due to posterior cerebral artery stroke. Single-word reading/spelling accuracy, reading latencies, and text reading were monitored as outcome measures for the combined effects of multiple oral re-reading treatment and interactive spelling treatment.

Results: After treatment, participants demonstrated faster and more accurate single-word reading and improved text-reading rates. Spelling accuracy also improved, particularly for untrained irregular words, demonstrating generalization of the trained interactive spelling strategy.

Conclusion: This case series characterizes concomitant LBL with surface alexia/agraphia and demonstrates a successful treatment approach to address both the reading and spelling impairment.

Figure 1.

(A) A cognitive model of written language processing depicting disruption of visual input to the orthographic lexicon (hash marks), an alternate letter-by-letter reading route (dashed lines), and graying of the orthographic lexicon to indicate damage. (B) Schematic depiction of the presumed effect of behavioral treatments, showing multiple oral re-reading treatment (MOR Tx) promoting whole word processing rather than letter-by-letter reading, and interactive spelling treatment promoting combined reliance on lexical and sublexical processing of information to support word recognition and spelling.

Figure 2.

Lesion maps for the three participants (left); average reading reaction times for four- to seven-letter words, with standard deviation bars (middle); reading and spelling performance on regular and irregular words (right). Lesions are normalized to standard MNI template depicting damage to left ventral occipito-temporal (lvOT) regions at z = −17 (leftmost) and z = −12. Red circles are 12 mm spheres indicating the location of the visual word form area (VWFA) derived from a meta-analysis of functional imaging studies of reading (Jobard, Crivello, & Tzourio-Mazoyer, 2003), and represent x = −44, y = −58, z = −15. *Significant regularity effect (p < .05).

Figure 3.

Treatment results for participant 1 (P1). (a) Reading rate on practiced passages; (b) reading rate and number of errors on untrained GORT–3 passages. (c) Pre- and posttreatment reading reaction times; (d) pre- and posttreatment reading/spelling accuracy. *Significant increases in text-reading rate (p < .001), single-word reading rate (p < .001), and overall spelling accuracy posttreatment (p < .05).

Figure 4.

Treatment results for participant 2 (P2). (a) Reading rate on practiced passages; (b) reading rate and number of errors on untrained GORT–3 passages. (c) Pre- and posttreatment reading reaction times; (d) pre- and posttreatment reading/spelling accuracy. *Significant increases in text-reading rate (p < .05), single-word reading rate (p < .01), and irregular word spelling accuracy posttreatment (p < .000).

Figure 5.

Treatment results for participant 3 (P3). (a) Reading rate on practiced passages; (b) reading rate and number of errors on untrained GORT–3 passages. (c) Pre- and posttreatment reading reaction times; (d) pre- and posttreatment reading/spelling accuracy. *Significant increases in text-reading rate (p < .01) and single-word reading rate (p < .000) posttreatment.

Figure 6.

Results of posttreatment self-rating questionnaire completed by the three participants with alexia and agraphia.